DEBRIDEMENT

Definition

Debridement is the process of removing dead (necrotic) tissue or foreign material from
and around a wound to expose healthy tissue.

Indication

An open wound or ulcer can not be properly evaluated until the dead tissue or foreign
matter is removed. Wounds that contain necrotic and ischemic (low oxygen content)
tissue take longer to close and heal. This is because necrotic tissue provides an ideal
growth medium for bacteria, especially for Bacteroides spp. and Clostridium perfringens
that causes the gas gangrene so feared in military medical practice. Though a wound may
not necessarily be infected, the bacteria can cause inflammation and strain the body's
ability to fight infection. Debridement is also used to treat pockets of pus called
abscesses. Abscesses can develop into a general infection that may invade the
bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue
exposed to corrosive substances tends to form a hard black crust, called an eschar, while
deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars
may also require debridement to promote healing.

Procedure

The four major debridement techniques are

surgical, mechanical, chemical, and autolytic.

Surgical debridement

Surgical debridement (also known as sharp

debridement) uses a scalpel, scissors, or other
instrument to cut necrotic tissue from a wound. It
is the quickest and most efficient method of debridement. It is the preferred method if
there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a
more generalized alized infection (sepsis) that has entered the bloodstream. The physician
starts by flushing the area with a saline (salt water) solution, and then applies a topical
anesthetic or antalgic gel to the edges of the wound to minimize pain. Using forceps to
grip the dead tissue, the physician cuts it away bit by bit with a scalpel or scissors.
Sometimes it is necessary to leave some dead tissue behind rather than disturb living
tissue. The physician may repeat the process again at another session.

Mechanical debridement

In mechanical debridement, a saline-

moistened dressing is allowed to dry
overnight and adhere to the dead tissue.
When the dressing is removed, the
dead tissue is pulled away too. This
process is one of the oldest methods of
debridement. It can be very painful
because the dressing can adhere to
living as well as nonliving tissue.
Because mechanical debridement cannot select between good and bad tissue, it is an
unacceptable debridement method for clean wounds where a new layer of healing cells is
already developing.

Chemical debridement

Chemical debridement makes use of certain enzymes and other compounds to dissolve
necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes
its own enzyme, collagenase, to break down collagen, one of the major building blocks of
skin. A pharmaceutical version of collagenase is available and is highly effective as a
debridement agent. As with other debridement techniques, the area first is flushed with
saline. Any crust of dead tissue is etched in a crosshatched pattern to allow the enzyme to
penetrate. A topical antibiotic is also applied to prevent introducing infection into the
bloodstream. A moist dressing is then placed over the wound.

Autolytic debridement

Autolytic debridement takes advantage of the body's own ability to dissolve dead tissue.
The key to the technique is keeping the wound moist, which can be accomplished with a
variety of dressings. These dressings help to trap wound fluid that contains growth
factors, enzymes, and immune cells that promote wound healing. Autolytic debridement
is more selective than any other debridement method, but it also takes the longest to
work. It is inappropriate for wounds that have become infected.

Biological debridement

Maggot therapy is a form of biological debridement known since antiquity. The larvae of
Lucilia sericata (greenbottle fly) are applied to the wound as these organisms can digest
necrotic tissue and pathogenic bacteria. The method is rapid and selective, although
patients are usually reluctant to submit to the procedure.

Diagnosis/Preparation

The physician or nurse will begin by assessing the need for debridement. The wound will
be examined, frequently by inserting a gloved finger into the wound to estimate the depth
of dead tissue and evaluate whether it lies close to other organs, bone, or important body
features. The assessment addresses the following points:

• the nature of the necrotic or ischemic tissue and the best debridement procedure to
follow
• the risk of spreading infection and the use of antibiotics
• the presence of underlying medical conditions causing the wound
• the extent of ischemia in the wound tissues
• the location of the wound in the body
 • the type of pain management to be used during the procedure

Nursing Responsibilities

Preoperative Care

• Make sure that identification band is present and complete

• Report all known allergies and recorded it and place an allergy wrist band if
indicated

• Check and record vital signs, report marked differences from baseline to the
surgeon and anesthesiologist

• Let the client sign the consent.

• Before surgical or mechanical debridement, the area may be flushed with a saline
solution, and an antalgic cream or injection may be applied.

• If the antalgic cream is used, it is usually applied over the exposed area some 90
minutes before the procedure.

• Remove dentures

• Remove jewelry and any piercings. If jewelry is removed, it should be stored

according to policy or given to the family.

• Dress the client with hospital gown and protective cap.

• Remove any makeup so skin color can be observed

Intraoperative Care

• Always keep concept of sterility in mind and in practice.

 • All items are counted initially by the circulating nurs and the scrub nurse together
(aloud) as the scrub person touches each item.
• The number (count) of type of each item is immediately recorded by the
circulating nurse.
• If there is uncertainty in the initial count, it is repeated.
• As additional items (e.g., sponges or needles) are added to the sterile field, during
the procedure, the scrub person accounts the items with the circulator, who adds
the count to the record and initials it.
• Whenever there is a change of team members, a count is taken.
• Counts are taken before beginning the procedure, before wound closure begins,
and when skin closure is initiated.
• All items (e.g., instruments, supplies, equipment) that come in contact with the
sterile field and the wound must be sterile.
• Pay attention to the surgeon, anticipating every instrument about to be asked.

Postoperative care

• After surgical debridement, the wound is usually packed with a dry dressing for a
day to control bleeding.
• Afterward, moist dressings are applied to promote wound healing. Moist
dressings are also used after mechanical, chemical, and autolytic debridement.
• Provide meticulous care of the dressing and irrigation setup
• Assess the client for manifestation of further infection.

AMPUTATION

Amputation is a
surgical procedure
that involves removal of an extremity/limb (leg or arm) or a part of a limb (such as a toe,
finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to
remove tumors from bones and muscles). About 1.8 million individuals in the US are
living with an amputation. Amputation of the leg (above and below-knee) is the most
common type of amputation procedure performed.

Indication

Arms, legs, hands, feet, fingers, and toes can be amputated. Most amputations involve
small body parts such as a finger, rather than an entire limb. About 65,000 amputations
are performed in the United States each year.
Amputation is performed for the following reasons:

• to remove tissue that no longer has an adequate blood supply

• to remove malignant tumors
• because of severe trauma to the body part

The blood supply to an extremity can be cut off because of injury to the blood vessel,
hardening of the arteries, arterial embolism, impaired circulation as a complication of
diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite,
Raynaud's disease, or Buerger's disease.
More than 90% of amputations performed in the United States are due to circulatory
complications of diabetes. Sixty to eighty percent of these operations involve the legs or
feet. Although attempts have been made in the United States to better manage diabetes
and the foot ulcers that can be complications of the disease, the number of resulting
amputations has not decreased.

Procedure
Amputations can be either planned or emergency procedures. Injury and arterial
embolisms are the main reasons for emergency amputations. The operation is performed
under regional or general anesthesia by a general or orthopedic surgeon in a hospital
operating room.
The surgeon makes an incision around the part to be amputated. The part is removed, and
the bone is smoothed. A flap is constructed of muscle, connective tissue, and skin to
cover the raw end of the bone. The flap is closed over the bone with sutures (surgical
stitches) that remain in place for about one month. Often, a rigid dressing or cast is
applied that stays in place for about two weeks.

Nursing Responsibilities

Preoperative Care

• Take the complete medical history of the patient.

• Instruct patient to fast for eight hours before the procedure, generally after
midnight.
• Report all known allergies and recorded it and place an allergy wrist band if
indicated

• Ask the patient if he/she is taking medications (prescription and over-the-counter)

and herbal supplements.
• Check if the patient have a history of bleeding disorders or if taking any
anticoagulant (blood-thinning) medications, aspirin, or other medications that
affect blood clotting.
• Tell patient that they may be measured for an artificial limb prior to the
procedure.
• Remove dentures

• Remove jewelry and any piercings. If jewelry is removed, it should be stored

according to policy or given to the family.

• Dress the client with hospital gown and protective cap.

 • Remove any makeup so skin color can be observed

Intraoperative Care

• The skin over the surgical site will be cleansed with an antiseptic solution.
• Always keep concept of sterility in mind and in practice.
• All items are counted initially by the circulating nurs and the scrub nurse together
(aloud) as the scrub person touches each item.
• The number (count) of type of each item is immediately recorded by the
circulating nurse.
• If there is uncertainty in the initial count, it is repeated.
• As additional items (e.g., sponges or needles) are added to the sterile field, during
the procedure, the scrub person accounts the items with the circulator, who adds
the count to the record and initials it.
• Whenever there is a change of team members, a count is taken.
• Counts are taken before beginning the procedure, before wound closure begins,
and when skin closure is initiated.
• All items (e.g., instruments, supplies, equipment) that come in contact with the
sterile field and the wound must be sterile.
• Pay attention to the surgeon, anticipating every instrument about to be asked.
•
• A sterile bandage/dressing will be applied. The type of dressing used will vary
according to the surgical technique performed.
• Place a stocking over the amputation site to hold drainage tubes and wound
dressings, or the limb may be placed in traction or a splint.

Postoperative Care

• Monitor the vital signs of the patient.

• Monitor circulation and sensation of the affected extremity .
• Give pain medications and antibiotics if prescribed.
• Change and monitor the amputation dressing very closely.
• Notify the physician if there is:
• fever and/or chills
• redness, swelling, or bleeding or other drainage from the incision site
• increased pain around the amputation site
• numbness and/or tingling in the remaining extremity